Summary On 29August 1998 three sport fishermen rented a boat from an outfitter to go fishing near the Carillon dam. When they returned from their outing that night, they had to row back to shore as the outboard motor which they had rented with the boat had been removed by the outfitter before sunset. At the same time the Carillon-to-Pointe-Fortune ferry ANIK was crossing the Ottawa River in heavy rain. The occupants of the boat shouted and waved their arms in an attempt to draw the attention of the ferry operator but they were unsuccessful. They jumped over the side without any flotation devices only seconds before the collision. Two of the three occupants managed to swim close to shore where they were rescued; the third person drowned, and divers retrieved his body from the water the next day. Ce rapport est galement disponible en franais. Other Factual Information Description of Vessels Rental Boat The rental boat was a 4.9m wooden, flat-bottomed boat of open construction, square at both ends; it was constructed of plywood over timber frames, and it had a raked stem. The boat was rented with the following equipment: an outboard motor (4kW or less); an anchor with line attached; two oars; one personal flotation device (PFD) for each person on board; one bailer; and a hand-held whistle. In this instance, as the boat was being operated between sunset and sunrise, the Collision Regulations required that a flashlight be carried on board. At the time of the accident, however, the boat was not equipped with an outboard motor, nor a flashlight, and the PFDs carried on board were approved in the United States but did not have a seal of approval from Transport Canada. The boat had no pyrotechnics, and none were required by regulations. The ANIK The ANIK is a privately operated double-ended ferry serving Carillon and Pointe-Fortune, Quebec, on the Ottawa River. The main deck extends beyond the ship's side to accommodate more vehicles. The navigation bridge is positioned at about mid-length and offset to one side of the ferry. The navigational instruments and the main engine controls are positioned on the inboard side such that they are at right angles to the direction of the vessel's travel. The navigation equipment includes a radar. A citizen's band (C.B.) radio provided a means of communication between the ferry and the owner. The ferry was not equipped with a very high frequency (VHF) radio, nor was such equipment required by regulations. Ferry Operation The ferry operates from April to December between the hours of 0600 and 2400 on an as-needed basis.[2] The ferry employs a crew of two, who work a nine-hour shift over the weekend. Each crew consists of a master, who has the conduct of the ferry navigating from the bridge, and a deck-hand, positioned on the main deck, in charge of loading and offloading vehicles and passengers. Rental Boat Operation The boat rental office is open from 0700 to 1900. A client wishing to rent a boat has to fill a rental contract form and provide basic information such as name, address, telephone number and driver's license number. The client signs the contract below the waiver clause and receives a receipt when returning the boat. The outfitter then places a small outboard motor (of 7.3kW or less) and safety equipment on board and provides basic information to the renters on how to operate the motor and don the lifejackets. The weather is not normally monitored by the outfitter and normally no weather forecast is provided to clients. Events Leading to the Occurrence On August 29 three men rented a boat from an outfitter to go fishing. At 1000, after completing the usual formalities, the men proceeded to the fishing area below the hydroelectric dam at Carillon. Before sunset, at approximately 1915, the outfitter went to the fishing area to advise the men that the rental period was over and to return the boat for the night. The clients then asked the outfitter to allow them to stay longer. As the rental outlet was unattended at night and nobody would be there to secure the equipment for the night, the outfitter, with the consent of the clients, took the outboard motor off the boat and returned to the dock. The three men agreed to use the oars to propel the boat back to shore. At about 2030, the sky became overcast and heavy rain moved in with winds from the south-southwest at 10km/h. With the weather deteriorating, the three men decided to return to the dock. They rowed along the south shore of the river, as the water seemed to be calmer there. When opposite the rental outlet, they cut across towards the north shore. The weather had deteriorated further and the waves had started to build up due to stronger winds. The current in the area was estimated to be easterly at two knots. The load in the boat was redistributed: two persons sat on the middle seat and rowed together, the third person sat on the forward seat. Meanwhile, around 2038, the ferry ANIK departed the Carillon ferry landing for the one in Pointe-Fortune, a distance of about 600m. The ferry was making approximately six knots and the crossing time was estimated at four to six minutes. The master was engaged in conducting navigation, steering and manoeuvring the ferry and maintaining a look-out. When the occupants of the boat saw the ferry heading towards them, they waved their arms and shouted to attract attention but the hand-held whistle was not used. Upon realizing that a collision was imminent and that the boat could not get out of the way of the ferry despite their efforts, the three occupants jumped into the water to avoid being injured; the men did not wear any PFDs. As the ferry maintained her course and speed, the two vessels collided. The starboard side of the boat came in contact with the port side of the ferry. The overhang of the ferry's deck caused the boat to heel to starboard and ship water because of the low freeboard of the boat--about 48cm--and the forward momentum of the ANIK caused the boat to slide along the ferry's hull. The boat ended up in the wake of the ferry, partly submerged. No one on the ferry was aware of the striking as no impact was felt. The collision occurred southeast of buoy H197, near Fortune Reef, at about 2045. The three occupants tried to rally together but they were unable to regroup. Given the circumstances, all three attempted to swim to shore, two of them together and the other on his own. The elder one from the group of two succumbed to exhaustion and drowned. The other two made it to shore but not without some difficulty. The water temperature at the time of the occurrence was about 22C and the air temperature was 15C. A passerby on the wharf at Carillon heard cries for help and he alerted persons in the ferry owner's house some 140m away. They rushed down to the dock with a life buoy, and from there saw the outline of a person in the water about 30m from shore. They encouraged him to continue swimming (for several minutes) until he was able to grab the life buoy, and they slowly hauled him to shore. Search and Rescue (SAR) Meanwhile, the ferry owner called the dispatcher of the Sret du Qubec (SQ) in Montreal, Quebec. The master of the ferry was immediately alerted by C.B. radio. Under instructions from the SQ, the ferry, which was manoeuvring to depart Pointe-Fortune, turned on the searchlights to help locate other survivors and the boat. The ferry proceeded toward Carillon at reduced speed. Upon arrival, the ferry disembarked passengers and vehicles. The ferry owner and one additional person joined in the search on board the ferry. Meanwhile, the second survivor had reached the shore. An ambulance called by the SQ arrived at the scene. First aid was rendered and both survivors were taken to a local hospital at Lachute, Quebec, where, following examination, they were released from the hospital the following day. The next day, the body of the victim was found along the north shore of the Ottawa River, two kilometres downstream. Local Emergency Arrangement The 9-1-1 emergency service is not available in the Carillon area. When an emergency occurs outside the regular office hours of the local SQ detachment, calls are relayed to a dispatcher at SQ headquarters in Montreal. According to established procedures, when a marine incident is reported to the SQ, it promptly notifies the Marine Rescue Sub-Centre (MRSC) in Qubec, Quebec.[3] This was done only several hours later. The ferry operator did not have in place an emergency procedure for SAR operations. Neither the Coast Guard Radio Station (CGRS), nor the Vessel Traffic Services (VTS) Centre, nor MRSC Qubec were notified immediately when the ferry owner became aware of the occurrence. It was not until several hours after the search by local authorities had been launched that MRSC became aware of the accident through the VTS Centre. In this instance, prompt action by local authorities to initiate the search mitigated the consequences of not alerting the MRSC. Watchkeeping Practices The Collision Regulations require that a proper look-out be maintained by sight and hearing as well as all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and the risk of collision. The Recommended Code of Nautical Procedures and Practices, 1985, TP1018, and established navigational practices provide guidance to personnel in charge of navigation.[4] They emphasize that the composition of the watch should be such that the vessel can be navigated safely, in that the workload associated with navigation activity takes into consideration weather, visibility, time of day, navigation hazards, traffic, ergonomics, etc. In this instance, despite reduced visibility, no dedicated look-out was posted on board the ferry. The small open boat was not fitted with a radar reflector, nor did it carry a flashlight. Qualification and Experience of Personnel The master of the ferry had a Master, Short Run Ferry Certificate of Competency issued in 1997. She had two years' experience on the ferry; the last year in the capacity of deck-hand/relief master. The occupants of the rented boat had no formal training in boat operations nor was such training required by regulations. Their experience was limited to that gained during times they had rented out a boat on a few occasions. Other Safety Initiatives At the time of the occurrence, discussions were ongoing between industry representatives and the Office of Boating Safety (OBS) of the Canadian Coast Guard (CCG) with respect to establishing guidelines for rental boat safety. The aim is to establish a common level of safe boating knowledge for operators of rented craft fitted with a motor. These include, among other things, the knowledge of safe boating principles and awareness of the obligation to comply with acts, regulations and codes. Further, the Contraventions Act, which was passed by Parliament in 1992, provides a streamlined means of addressing regulatory offences. The OBS has availed itself of the ease of enforcement afforded by the Contraventions Act by ensuring that the provisions of its legislation are designated as a contravention to regulations as covered by the Act. Fishing Near the Carillon Dam The investigation revealed an additional safety deficiency which, although it is not directly connected to the occurrence, has the potential to compromise transportation safety if left unaddressed. Anglers fish below the Carillon dam because fish are plentiful due to the barrier made by the hydroelectric dam and the associated high level of oxygen in the water flowing through the turbines. Warning signs posted by the operator of the dam state that boats should not be tied or anchored close to the dam. The warning signs are not always obeyed and there is no means to warn the controllers at the dam of the presence of boats in the vicinity of the dam. Further, the procedures established by Hydro-Qubec do not call for visual examination of the dam area before the turbines are operated. Passenger Count In case of an emergency, information respecting the number of passengers on board the ferry or the number of persons in the rental boat is not readily available for prompt and effective deployment of SAR resources; this could jeopardize the success of a SAR mission. Safety Action Taken by Transport Canada In a separate accident that occurred on 12September 1995 off the northwest coast of Hippa Island, Queen Charlotte Islands, British Columbia, the small open boat CHARLOTTE EXPLORER4 capsized with the subsequent death of two persons (TSB Report No.M95W0140). In its report on that occurrence, the Board expressed concern and noted that given the safety issues identified in tourist charter operations in Canada, practices within the wilderness fishing industry as a whole should be reviewed further. The Board believes that Transport Canada, the Canadian Coast Guard and the industry are those best placed to cooperate in an examination of current practices and to consider the best means of mitigating the risks resulting from identified safety deficiencies such as those contained in the report. Possible options could include regulatory requirements, an industry code of practice monitored by Transport Canada, or voluntary standards set and monitored by the industry itself. In response, Transport Canada issued a Ship Safety Bulletin (SSB No.01/99) regarding sport fishing. The bulletin recommends that operators adopt five basic standard procedures, as follows: Ensure that all craft, rented, loaned or chartered, comply with the requirements of the Small Vessel Regulations made pursuant to the Canada Shipping Act. Ensure that clients using these craft are made aware of, and are familiar with, the requirements of the Recreational Vessel Operator Proficiency Regulations of the Canada Shipping Act, and are familiar with radio and distress procedures. Ensure clients are either aware of inherent dangers presented by local sub-surface geography, weather and sea conditions, or only participate under the close supervision of experienced persons or fishing masters. Ensure regular radio contact and/or physical checks are made with clients at frequent intervals. Implement a buddy system, where possible, between clients while fishing.